taskshifting: translating theory into practice to build a

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Taskshifting: translating theory into practice to build a community based mental health care system in rural

Haiti, Intervention 2015, Volume 13, Number 3, Page 248 - 267

Taskshifting: translating theory intopractice to build a community basedmental health care system inrural Haiti

Rupinder Legha, Eddy Eustache,TatianaTherosme, Kate Boyd,Fils-Aime Reginald, Gertruna Hilaire, Shin Daimyo, GregoryJerome,HelenVerdeli & Giuseppe Raviola

In 2012, Zanmi Lasante, a Haitian nonpro¢t

organisation, along with its sister organisation,

Partners in Health, developed a mental health

plan intended to go beyond the immediate post

earthquake context by building capacity for

mental health and psychosocial services within

primary care services at 11 Zanmi Lasante sites

throughout Haiti’s Central Plateau and Artibonite

regions.This paper describes laying the foundation

for a community based, mental health care system

through the articulation of a ‘depression care

pathway’, in which patients are identi¢ed and

treated within the community, but referred to

clinics and more specialised care when required.

We emphasise taskshifting clinical, service delivery,

systems building, and quality improvement

responsibilities to psychologists, the central players

in the Zanmi Lasante mental health model. By

describing challenges and providing practical,

implementable solutions, we highlight how this

fundamental theory in global mental health

translates into daily practice in a health care

setting with limited biomedical services, clinical

training and human resources. We also provide

recommendations for optimising taskshifting

when initiating community based mental health

services in similar resource limited settings.

Keywords:Haiti, capacity building, healthcare: integration of mental health in generalhealth care

ht © War Trauma Foundation. Unautho248

ri

Key implications for practice� Taskshifting clinical responsibilities,

service delivery, systems buildingandquality improvement topsychol-ogists.

� Describes challenges and providespractical, implementable solutions.

� Canbeused indailypractice settingswith limited biomedical services,clinical training and humanresources.

� Recommendations for optimisingtaskshifting in initiating communitybased mental health services in lowresource settings.

ze

Introduction: backgroundHaiti’s 2010 earthquake, and subsequentcholera epidemic, represented additionaltraumas for a country that has been deeplyimpacted by: extreme poverty; AIDS andother deadly diseases; violence; andpolitical and economic interference by theinternational community (Bolton, Surkan,Gray, & Demousseaux, 2012). The earth-quake created massive casualties, internaldisplacement, and disruption of economic,

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Legha et al.

community, and family structures. It alsoexposed a mental health system unequippedto care for the severely mentally ill prior tothe earthquake (Sontag,2010), and therefore,completely unprepared to address theadditional trauma and su¡ering caused bythe earthquake (Cerda, 2012). However, itprominently placed mental health on theHaitian government’s agenda, and duringthe following year, the Ministry of Health(Ministe' re de la Sante¤ Publique et de laPopulation, MSPP) held meetings with keystakeholders to move towards a nationalmental health policy. Despite these promis-ing e¡orts, there remains no well-de¢nedmental health agenda to guide service pro-vision (Raviola, Severe,Therosme, Oswald,Belkin, G. & Eustache, 2013).

Mental health care in HaitiData, while limited, indicates a high preva-lence of depression and suicidal ideation(Wagenaar, Hagaman, Kaiser, McLean, &Kohrt,2012), emotional distress due to organ-ised violence and life stressors (Boltonet al., 2012; Smith-Fawzi et al., 2010), andtrauma related to the 2010 earthquake(Cerda¤ et al., 2012; Wagenaar et al., 2012).Approximately ten psychiatrists and ninepsychiatric nurses work in Port-au-Prince,removed from the rural Haiti, where 60%of the population resides. Additionally, thetwo public psychiatric hospitals, UniversityHospital Center of Psychiatry Mars andKline and Beudet, are under¢nanced,understa¡ed and unable to provide highquality care.Additionally, due to lackof infrastructure, nopsychology licensing requirements or pro-fessional boards exist to oversee quality ofcare; instead psychologists are e¡ectivelylicensed after completing their bachelor’sdegree. Psychology bachelor’s degrees inHaiti focus largely on theory and didacticteaching, so required clinical rotations lackstandardisation and established competen-cies, due to lack of human resources andthe prohibitive cost of such training. Also,

ht © War Trauma Foundation. Unautho

for example, physicians receive limiteddidactic or clinical instruction in mentalhealth during medical school.While duringnursing school, nurses may spend severalweeks at one of the public psychiatric facili-ties in Port-au-Prince. However, neithergroup receives training in rights based, biopsychosocial approaches to evaluation andtreatment. Social workers may take severalcourses related to mental health, but alsoreceive no clinical training.Due to the fact that no national formulary ortreatment protocols exist, and adequatemental health training is unavailable, gener-alist physicians frequently refer patients tothese facilities rather than manage themindependently (World Health Organization(WHO), 2011). Patients and families alsooften believe mental illness stems from out-side, supernatural forces and, therefore, seektreatment from church and traditionalheaers before seeking biomedical treatment,which is more di⁄cult to access (Wagenaar,Kohrt, Hagaman, McLean, & Kaiser,2013). Local communities o¡er support forthe mentally ill, although stigmatisationremains common (Brodwin, 1996; WHO/Pan American Health Organization(PAHO), 2010).

Developing a community based,mental health care system inrural HaitiPartners in Health (PIH), a Boston basednon pro¢t organisation that providesequitable, quality health care worldwide,and Zanmi Lasante (ZL), its Haitian sisterorganisation, have worked together for over25 years, serving approximately 1.2 millionpeople in Haiti’s Central Plateau and Arti-bonite Valley. Community health workerbased care for HIV and tuberculosis pro-vided an appropriate foundation for devel-oping a similar community based,integrated model of mental health care.Prior to the earthquake, ZL’s PsychosocialSupport Department consisted of three psy-chologists and 20 social workers and social

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worker assistants, who focused primarily onsocio economic, educational and psychologi-cal needs of children and families a¡ectedby HIV/AIDS and tuberculosis (Raviola,Eustache, Oswald, & Belkin, 2012). ForHIV/AIDS patients, they provided brief pretest, post test and medication adherencecounselling, lasting approximately 15^20minutes. During these sessions, they pro-vided informed consent for testing,explained the implications of positive andnegative tests, shared test results, providedemotional support as needed, and explainedtreatment plans. However, they did not con-duct comprehensive mental health evalu-ations. Following the earthquake, MSPPrequested PIH and ZL’s support in develop-ing a nationalmental health plan that wouldserve immediate needs while laying thefoundation for a sustainable model of care.By February 2010, the newly integratedPIH/ZL mental health and psychosocialteam was addressing acute mental healthneeds in internally displaced persons campsin Port-au-Prince, and training doctors andnurses at key ZL sites in basic mental healthevaluation and treatment.

Scaling up mental health services atZanmi LasanteIn 2012, ZL received a three-year GrandChallenges Canada (GCC) Grant to gobeyond immediate post earthquake needsbydeveloping sustainablemental healthcarein ruralHaiti.Theprimarygoals are tobuildcapacity for overall mental health and psy-chosocial services within primary care ser-vices at the 11 ZL sites in the CentralPlateau and Artibonite regions, and to sup-port MSPP in developing a national, decen-tralised mental health programme(Raviola et al., 2012; Raviola et al., 2013).Post earthquake e¡orts had laid the founda-tion for developing a sustainable mentalhealth model. However, the subsequent scal-ing-upandtaskshiftinge¡orts for the depres-sion care pathway called for community


healthworkers, nurses, physicians, psycholo-gists, and social workers to assume speci¢ctasks and collaborate to ensure patients areidenti¢ed and treated in the communityand referred to clinics and hospitals whenneeded.This care pathway represented a tre-mendous increase in the magnitude of men-tal health service provision, especially forpsychologists, but also for ZL clinicianswho generally lacked previous substantivemental health training.Thus, the newexpec-tations from the depression system of carewere both innovative and ambitious.Data from this paper were drawn from theGCC funded project, entitled ‘Evaluation ofa new implementation model to addresssevere mental disorders in rural Haiti toinform the development of a national decen-tralized mental health plan following the2010 Haiti earthquake.’ The InstitutionalReview Board (IRB) of the HarvardUniversity FacultyofMedicine reviewed thisprotocol and determined that it did notconstitute human subjects research. The ZLEthics Committee, which serves as the IRBfor ZL projects, approved this project ashuman subjects research.

Taskshifting and the critical role ofpsychologists, pre implementationplanDe¢nedby theWHOas the rational redistri-bution of tasks among health workforceteams, taskshifting redistributes responsibil-ities from higher trained health workers toless highly trained health workers, in orderto maximise e⁄ciency of health workforceresources (WHO, 2008). To operationalisetaskshifting within the ZL mental healthcare system, skill packages from the ‘5�5’model (see below) werematched to providerroles, prior to implementation (Figure 1).Psychologists were additionally tasked withserving as site leaders in care delivery andsystems building, by advocating for mentalhealth patients, bridging the gap betweencommunity and clinic, and supporting other

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Acute

CommunityFollow-up andIPT(CHW)

Screenwith

ZLDSI

Hospital/clinicrescreenmental healthevaluation(psychologist/SW)

Less acute

Physician

Medication

>13–17>13–17

>18

>28–39

Hospital/cliniccase

identification(nurse)

Communitycase

identification(CHW)

Psychologist/SW

IPT

Figure 1: Zanmi Lasante depression care pathway.

Legha et al.

clinicians to include mental health care inthe comprehensive package of services.Furthermore, they were given primaryresponsibility for maintaining a registry ofmental health patients seen at their sitesand submittingmonthly reports that capturekey data about patient demographics andclinical work. This data collection, to besupervised by a member of the ZL monitor-ing and evaluation (M&E) team, wasintended to drive quality care provision.Thus, psychologists were charged withclinical, service delivery, systems building,and quality improvement responsibilities tolay the foundation for the ZL mentalhealth system.

The ‘5T5’modelPIH and ZL developed this communitybased, mental health model based on the‘5�5’ intervention, which guides the scalingup of culturally based, mental health ser-vices in low resource settings, with limitedpreexisting services. It assigns communityhealth workers (CHWs), psychologists,social workers, nurses and generalistphysicians ¢ve skill packages: case ¢nding,engagement, follow-up and psychoeducation; psychological interventions;


medication management; supervisionand consultation; and quality oversight.These are articulated through ¢ve imple-mentation rules: 1) assess context ¢rst; 2)identify priority care pathways and mapthem across skill packages; 3) specifydecision supports, supervision, and triagerules; 4) use quality improvement practices;and 5) plan for sustainability andcapacity building.The framework speaks of the importance ofa shared vocabulary and tools for coordinat-ing and comparing mental health scale upe¡orts across diverse settings (Belkin et al.,2011). After completing the ¢rst three imple-mentation rules, PIH and ZL prioritised adepression care pathway, based on themhGAP (clinical management of mentalhealth and substance use conditions) inter-vention guide and built on the aforemen-tioned role providers, which was intendedto lay the groundwork for a system of mentalhealth care during year one of the GCCinitiative. Additional, evidence based, cultu-rally adapted care pathways were to bedeveloped and implemented for epilepsy,bipolar and psychotic disorders and childand adolescent disorders during years twoand three.


Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.

MH in context of stigma,culture, religion

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MH and human rights

Familiarity with MH carepathwaysFamiliarity with mainsymptom groups anddisorders

Screeing tool use

Mental statusexaminationTriage rules for prioritymental disordersRational for acceptedtreatment approaches

Active and empathiclistening skillsBehavioral activationtechniquesRelaxation techniques

Manualiation psycho-therapies (e.g., IPT andCBT adapted tocontext)

TOT (psychotherapies)

Recognition of sideeffects of medication

Medication adherencesupport

Main medication types,side effectsMedical mangement ofpriority mentaldisordersResponding to MH crises

Managing acute MHcrises + physicalrestraint

Familiarity with epilepsy

Specialised knowledge ofneurologic disordersSpecialised knowledge ofchild/adolescent MHManagement of qualityimprovement

Skill package Color

General knowledge

Triage-enagement-education-support

Psychotherapy

Pharmacotherapy

Specialist care/referral

Quality/oversight

Figure 2: Mapping skill areas to provider roles, from Raviola et al. 2012.



252

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Legha et al.

Depression care pathway developmentand provider rolesThe depression care pathway (Figure 2)depends on a locally validated, depressionscreening and monitoring tool: the Zanmi

LasanteDepression Screening Inventory (ZLDSI)(Rasmussen, Eustache, Raviola, Kaiser,Grelotti, & Belkin, 2015). CHWs refer severecases, determined by ZLDSI scores, to psy-chologists and social workers and they man-age less severe cases within the community.Based on the ZLDSI score, safety issues,severity, and medical concerns, psycholo-gists and social workers then refer moreacute patients to generalist physicians formedication management. Psychologists andsocial workers conduct comprehensive men-tal health evaluations and manage themajority of cases with psychotherapy(including aversion of interpersonal therapyadapted to the Haitian context), psycho edu-cation, behavioural activation, and relaxa-tion techniques. As patients improve, theyreturn to the community, where CHWsresume caring for them using a simpli¢edversion of the interpersonal therapy (IPT)adapted to the Haitian context. Nursesidentify depression cases within the clinicor hospital and refer them to psychologistsand social workers. Notably, within thedepressioncare pathway, socialworkerswereasked to perform the same clinical responsi-bilities as psychologists.

Curriculum development anddepression care pathway trainingDrawingonthree decades of successful train-ing in diverse, resource limited settings, thePIH training team developed four depres-sion curricula for CHWs, nurses, physicians,social workers and psychologists. The psy-chologist training consisted of power-pointpresentations, group exercises, open discus-sion and question/answer sessions thatreviewed mental health and wellbeing froma human rights perspective, the ZL mentalhealth care system, psychologists’ unique


leadership role, diagnosing major mentalillness categories using DSM-IV, compre-hensive mental health evaluation and biopsychosocial case formulation, the aetiologyand treatment of depression and psychologi-cal treatments.The trainingalso emphasisedhow to use mhGAP and the ZLDSI, andreviewed basic interpersonal therapy skills,along with behavioural activation andrelaxation exercises.During the summer of 2013,31CHWs,21psy-chologists and social workers, 21 nurses, and11 physicians trained for 3^5 days in basicmental health concepts related to diagnosis,evaluation, and treatment, based on theirroles in the care pathway. Trainings tookplace separately among role providers, soall CHWs trained together, all nursestrained together, and all physicians trainedtogether. Psychologists and social workerstrained together because they were to playthe same clinical role in the depression carepathway. Members of the ZL mental healthteam carefully selected trainees by identify-ing potential mental health champions, thatis: one to two nurses and physicians fromeach site who were leaders, or had demon-strated a strong interest in mental health.The team supervisors (see below) all partici-pated in the trainings with themain supervi-sor for each clinician group taking the lead(Table1). Pre and post test, whichwere basedon the content of the trainings and demon-strated signi¢cant uptake of information(Table 2).

Training and supervisionFor the GCC initiative, one psychologist wasplaced at each of the 11 ZL sites. Severalhad worked for ZL since the earthquake,but most were newly hired. All had com-pleted coursework for psychology bachelor’sdegrees, although some had not completedtheses required for graduation. Some psy-chologists had received limited supervisionthrough previous positions with nongovern-mental organisations and apprenticeship



Table 1. Providers in the ZLmental health system of care

Zanmi Lasante mental health and psychosocial support services (MHPSS) teamPsychologists � 1psychologist at each of the10 ZL sites,

2 at 1ZL site;12 total�Full-timemental healthclinicians;mental

health leaders at each individual ZL site� 10 out of 12 completed 3-day depression

training (conducted jointly with socialworkers)

Social workers � 1at each of the11ZL sites;11total� 75% of their time dedicated to mental

health care; responsible for managingmental health patients, along withpsychologists

� 10 out of 11completed 3-day depressiontraining (conducted jointly withpsychologists)

Team supervisors � 1Psychologist Supervisor (forpsychologists and social workers)

� 1CHWSupervisor� 1Nurse Supervisor� 1Physician Supervisor� 1MEQSupervisor� 1 (American)TeamPsychiatrist (Pagenel

Fellow)�Full-timemental health clinicians/leaders�Responsible for supervising clinicians

who participated in training and foroperationalising depression carepathway at all 11ZL sites

Zanmi Lasante sta¡ who collaborate with MHPSS teamMental health community health workers

(CHW)� 2^3 at each of the11ZL sites; 31total

�Work part-time in mental health (mostCHWs do other health relatedcommunity health worker activities)

� 31out of 31completed 5-day depressiontraining

Nurses � 2^3 from each of the11ZL sites selectedfor depression training

�Not mental health team employees; workfor ZL in inpatient medical/primarycare



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� 21completed the 3-day depressiontraining

Physicians �1^2physicians fromeachof the11ZL sitesselected for depression training

�Not mental health team employees; workfor ZL in inpatient medical/primarycare

� 11completed the 3-day depressiontraining

Table 1. (Continued)

Legha et al.

with other clinicians. However, most psy-chologists had not received regular, long-term, direct clinical supervision, which wasto be a hallmark of the GCC initiative. ZLpsychologists often treat patients with exten-sive trauma histories, compounded bymedical illness, and further complicated bychallenges accessing treatment. These casesrequire advanced bio psychosocial evalu-ation and treatment formulation that isbeyond the focus of bachelor’s programmes.Therefore, psychologists required additionalsupervision to meet patients’ needs.

Teams supervisorsPIH hired a full-time psychiatrist, the Dr.Mario Pagenel Fellow in Global MentalHealth Delivery, to provide this supervisionwhile also supporting quality mental healthcare implementation and systems develop-ment. Rather than providing direct clinicalcare, the Fellow supervises ZL clinicians


Table 2. Pre test and post test scores:depression training

Clinician Pre test Post test

Community health worker 62% 86%Nurse 49% 85%Physician 53% 85%Psychologist 52% 67%Social worker 48% 66%All providers 50% 76%

(including psychologists, social workers,physicians, nurses and CHWs) who thenfunction as the primary providers of mentalhealth care. The ¢rst psychiatrist worked inHaiti from August 2011 through June 2012,and the second psychiatrist, who arrived inAugust 2013, will remain in Haiti throughDecember 2015.As part of the GCC grant, one supervisorwas given the responsibility of training itscadre at all 11 sites in order to operationalisethe depression care pathway. For example,the Physician Supervisor, a generalist phys-ician, was to supervise all ZL physicians;the CHW Supervisor, a psychologist, wasto supervise all CHWs; andaNurse Supervi-sor was to supervise all nurses. Another psy-chologist was to serve as the PsychologistSupervisor, overseeing all psychologists andsocial workers. This emergence of theseteams supervisors (seeTable 1) ensured thatsupervision, capacity building, and sustain-ability, key components of the 5�5 model,were prioritised. The Pagenel Fellow(team psychiatrist) was given the responsi-bility of standardising and improving super-vision in order to ensure ongoing, qualityimprovement.

Implementation of thedepression care pathway andchallengesTo support the burgeoning system of care,team supervisors began site visits.These sitevisits quickly revealed how the skill packagesmapped across care providers (Figure 2).


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However, while useful as a preliminaryguideline, these skill packages did not ade-quately meet the need for building compe-tencies in these areas. In particular, theskill packages did not outlinehow to: developthe systems building; service delivery;monitoring and evaluation; and qualityimprovement competencies that psycholo-gistswere supposed tomaster. Below, variouschallenges arising that related to taskshiftingresponsibilities to psychologists are dis-cussed, followed by associated solutions(Table 3).

Clinical responsibility challengesA novel, ¢ve-paged initial evaluation formprovided a framework for comprehensivemental health evaluations. However, mostpsychologists, lacking supervision in com-prehensive evaluations, limited their historyto one paragraph on the ¢rst page and over-looked additional information, like pasthistory and the mental status exam. Manypsychologists used the ZLDSI for patientswith strong suspicion of depression (forexample, suicidal patients). However, bipo-lar and dementia cases often did not receivethe depression screening necessary forproper diagnosis. Furthermore, the ZLDSIwas not used consistently enough to trackclinical improvement. Systematicapproaches to diagnosis and treatment pre-sented during the summer training, and out-lined in the depression care pathway,mhGAP, the DSM-IVand the IPT manualwere all adapted to the Haitian context,and yet were not implemented. Evaluationsalso lacked the advanced bio psychosocialformulations and treatment plans criticalfor complex patients with extensive traumahistories, co morbid medical illness and liv-ing in extreme poverty.A number of psychologists excelled in theirability to connect with patients and theirfamilies, but empathic listening, appropriatebody language and using open ended/closeended questions to complete evaluationswere di⁄cult for others. Cases of severe


mental illness, especially psychosis andmania, provoked discomfort regardingassessing safety, conducting a comprehen-sive evaluation (for example, by consultingwith family members for additional history)and using psychological interventions, suchas giving support and psycho education intandem with psychopharmacologic treat-ment. Psychologists demonstrated greateraptitude managing depressed and anxiouspatients, who are more amenable to psycho-logical therapies. To address clinical chal-lenges, the team supervisors developed aweekly IPTsupervision phone call and pro-vided clinical supervision in real time,directly or by phone. Additionally, whilesome psychologists subsequently improvedtheir skills, many considered supervision aburden that interfered with their growingclinical responsibilities.

Service delivery and systems buildingchallengesDocumentation and organisation, thefoundation of e¡ective service delivery andsystems building, presented some of themajor challenges. Required forms includedthe ¢ve-page initial mental health evalu-ation, a two-page follow-up form to trackclinical progression, the ZLDSI, and adepression care pathway form for capturingprovider collaboration. Psychologists werealso expected to enter patient informationinto a registry formonitoring and evaluationdata, in order to ensure patient follow-upand retention. Implementation was slowedby the unavailability of forms (most sitesdo not have printers), but also largelybecause documentation requirements wereconsidered excessive and contradicted mostpsychologists’ previous approach of writinga brief paragraph on blank paper. Prior tothe mental health scale-up e¡orts, psycholo-gist had relied primarily on nurses and phys-icians to refer tuberculosis and HIV/AIDSpatients for counselling, and all care wastracked through brief documentation inmedical dossiers. As such, they were



Table3.

Psych

olog

istco

mpe

tenc

iesin

theZLmen

talh

ealthcare

system

:assoc

iatedch

alleng

esan

dsolution

s

Com

petency

Cha

lleng

esSo

lution

s

Clin

icalcare

-Com

prehensive

mentalh

ealthevaluation

-Directsup

ervision

-Insu⁄

cientu

seofZLDSI

-Teachingindividu

alpa

rtso

fthe

evaluation

¢rst

-Systematicap

proachesto

diag

nosis

before

focusing

oncomprehensive

evaluation

-Adv

ancedbiop

sychosocialformulation

-Develop

ingbiop

sychosocialformulationskillsa

fter

mastering

theevaluation

-Interview

skills,therap

euticallia

nce

-Sup

ervisorsdemon

strating

interviewskills

-Man

agem

ento

fseverementalilln

ess

-Sup

ervising

useofform

s-Safetyassessments

-Intensive

(weekly),stand

ardisedsupervisionwith

specialist(psychiatrist)present

-Resistanceto

supervision

-Develop

ingtools/checklists/protocolsto

guide

supervision

-Multiplesupervisionmod

alities(ph

one,in-person,

casediscussion

,formalcasepresentation

,caseload

review

,con

sultationwith

colleag

ue)

-Stand

ardisedsitevisitsfocusedon

system

sbuilding

(not

max

imisingqu

antity

ofpatientsseen)

-Hom

eworkassign

ments

-Mon

thlypsycho

logistmeeting

s-Exam

Servicedeliv

eryan

dsystem

sbuilding

-Docum

entation

-Folders,¢

lingcabinetsto

organisepatient¢

les

-Organ

isation

-Persona

lsecured

¢lingsystem

fordo

ssiers

-Patient

archives

-Useofcalend

arsa

ndpo

st-it

notesfor

schedu

ling

-Collabo

ration

betw

eenproviders

-Directa

ndproactivesupervisionofcolla

boration

betw

eenroleproviders

Legha et al.

257


Com

petency

Cha

lleng

esSo

lution

s

-Scheduling

-Providing

toolsand

directsupervisionoforganisation

-Patient

engagementa

ndretention

-Reviewingchartsto

ensure

completedo

cumentation

-Triage

-Collabo

ration

withproviders,especially

CHWs

-Leadershipat

site,w

ithincommun

ityMon

itoring

andevaluation,q

uality

improvem

ent

-Using

registry

andcompletingmon

thly

repo

rts

-Directsup

ervision

ofregistriesby

multiple

stakeholders

-Using

mon

itoring

andevaluation

toim

prove

clinicalcare

andsystem

sbuilding

-Using

mon

thlyrepo

rtsd

uringweeklysupervision

-Accepting

andrespon

ding

tofeedba

ck-U

sing

mon

itoring

andevaluation

¢nding

sregularly

toshift

supervisionan

dto

shap

emon

thly

psycho

logistmeeting

sMan

agem

enta

ndlead

ership

-Rem

ediation/recou

rseforpo

orperforman

ce-Psycholog

istcom

petencies

-Sup

port/oversight

forallroleproviders

-Clear

repercussion

sfor

notfollowingrules

-Coh

esionam

ongZLmentalh

ealthteam

lead

ership/sup

ervisors

-Moreregu

larmeeting

sabo

utlead

ership

-Warning

lettersthrou

ghhu

man

resources

-Sup

ervision

arequ

ired

partofthejob

Table3.

(Con

tinu

ed)



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Legha et al.

unaccustomed to managing a caseload ofpatients independently as the primaryclinicians. Therefore, when the mentalhealth scale-up e¡orts began, psychologistslacked calendars to schedule patients,folders to ¢le patient materials, and docu-ments for monitoring and evaluationpurposes. Incomplete patient ¢les, limitedregistry use to track patients, and nocalendar for scheduling patients, in turn,interfered with treatment retention andre-engagement. Also, sites with paper based,centralised archives frequently lost ¢les,and psychologists frequently either re-evaluated patients with missing documen-tation, or wasted time searching fordossiers, further undermining documen-tation requirements.Patients often lacked resources to arrangetransport to clinic or could not a¡ord to losedaily wages. Some psychologists, as a result,communicated with patients by phone, orbyaskingCHWsto dohome visits as they felttoo overwhelmed by their existing responsi-bilities to do home visits themselves. As aresult, numerous patients were lost to fol-low-up. With no system for scheduling,patients often showed up randomly. So, psy-chologists could see no patients one day ormultiple acute cases on another day, makingtriage for acute cases di⁄cult and hinderingtreatment engagement for patients whospent the whole day waiting for care.Psychologists also often encountered di⁄-culty collaborating with primary care phys-icians, who were sometimes responsible formanaging dozens of patients each day. Inaddition to being overwhelmed by existingcaseloads, physicians also felt uncomfortablemanaging mental health patients, due totheir limited training in mental health. Asonly 11 ZL physicians had participated inthe depression training, the vast majority ofphysicians at the sites were unfamiliar withthe depression care pathway, including itstriage and decision rules, as well as the needto collaborate with psychologists. How-ever, comparatively speaking, collaboration


progressed, likely because patients neededmedical care (Table 4).Most psychologists did not e¡ectively collab-orate with CHWs to facilitate referrals toand from the community. Due to social andeducational hierarchies, some psychologistswere biased towards CHWs and did notbelieve they could deliver mental healthcare. More psychologists, however, wereunsure of how to provide multi-disciplinarycare through the community based model(Table 4). Therefore, most patients self-pre-sented or were referred from other clinicalproviders within the hospital/clinic settings,rather than from the local community.Indeed, many psychologists focused solelyon their individual clinical encounter withtheir patient in their o⁄ce. Overwhelmedby their various new responsibilities, theyfelt uncomfortable enhancing service deliv-ery throughout the clinic/hospital site, forexample by collaborating with nurses andphysicians in the inpatient setting.One socialworker at eachZL sitehadbeenasked to con-tribute signi¢cantly to mental health (seeTable 1). Because social workers receive noclinical exposure to mental health duringtheir training, they required supervision.However, the psychologist supervisor wasalso occupied with training all 12 psycholo-gists. Social workers’ responsibilities, unre-lated to mental health, also prevented themfrom committing 75% of their time to men-tal health, as originally planned.Therefore,as a whole, they remained uninvolved inthe depression care pathway.

Monitoring and evaluation challengesThe ZL monitoring, evaluation, and qualityimprovement (MEQ) team created a regis-try to document patient demographics, diag-noses, and treatments for each visit.Psychologists used the registries to generatemonthly reports capturing clinical care, ser-vice delivery, and systems-buildingindicators. Examples of these indicatorsinclude: number of new patients, number offollow-up patients, number of patients



Table4.

Collabo

ration

betw

eenrole

prov

idersat

sitesthat

received

site

visitsu

perv

ision

Octob

er2013

(2mon

ths

aftertraining

s)Februa

ry2014

(6mon

ths

aftertraining

s)May

2014

(9mon

ths

aftertraining

s)

Patientsreferred

from

CHW

topsycho

logist/SW

Site1:0

Site1:0

Site1:2

Site2:7

Site2:1

Site2:6

Site3:3

Site3:0

Site3:0

Patientsreferred

from

psycho

logist/SW

toCHW

Site1:0

Site1:0

Site1:3

Site2:0

Site2:0

Site2:0

Site3:0

Site3:0

Site3:0

Patientsreferred

from

physician/

nurseto

psycho

logist

Site1:0

Site1:16

Site1:8

Site2:23

Site2:16

Site2:39

Site3:0

Site3:6

Site3:12

Patientsreferred

from

psycho

logistto

physician/nu

rse

Site1:0

Site1:16

Site1:15

Site2:35

Site2:11

Site2:78

Site3:0

Site3:8

Site3:17

Collaborationbetweenpsychologistsandphysicians/nursesprogressedsteadily,especiallyafterstandardisedsitevisitsbeganinFebruary2014.How

ever,collaborationbetweencommunityhealthworkers(CHWs)

andpsychologistsdidnot.Notethatsocialworkers(SW)aregroupedwithpsychologistsbecausebotharetheprimarymentalhealthcareprovidersateachclinicalsite.D

atareportedas‘0’indicatesthateitherdata

wasnotreported,orcollaborationdidnottakeplace.



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receiving interpersonal therapy, and num-ber of patients referred from nurses andphysicians. During the ¢rst six months ofimplementation, registries often remainedunused, andmonthly reportswere submittedlate or incorrectly,makingdata driven, qual-ity improvement unfeasible.The othermajormonitoringandevaluationtool, direct super-vision led by the psychologist supervisor,aimed to improve psychologists’ skills inclinical, service delivery, and systems build-ing domains. Several psychologistsresponded positively; but many psycholo-gists felt undermined by the supervision,considering it an additional task or burdento manage in the midst of a substantialincrease in workload.

Improving implementation:solutions to challengesDirect supervision as key to clinicalcarePrior to scale-up e¡orts, supervision hadbeen informal and optional, initiated onlywhen psychologists requested it.While teamsupervisors had expertise to share, mosthad not been trained under formal supervi-sion themselves. The team psychiatrist, whoarrived after all four depression trainingswere completed, generated momentum fora consistent supervision process. Althougheach supervisor focused on their assignedcadre, all team supervisors worked with thepsychologists, due to their central role.Direct clinical supervision in the ¢eldquickly revealed common gaps in knowl-edge. As a result, team supervisors sub-sequently developed supervision tools toaddress them. One-page guides on: conduct-ing mental status exams, suicide/safetyassessments and gathering social historiesprovided practical, implementable edu-cation. Team supervisors also assisted psy-chologists with the basic components of theMH evaluation ¢rst, and then progressedto assisting in developing more advancedclinical skills related to diagnosis and


treatment. Through providing supervisionin person, team supervisors demonstratedinterview skills, showing empathy topatientsand preventing con¢dentiality breaches inorder to develop a therapeutic alliance. Asthe psychologists’ skills improved, teamsupervisors were able to focus more on diag-nosis and case formulation.The team’s psychiatrist standardised super-vision by emphasising consistent use of keyteaching materials, such as the mhGAP, thedepression training, the DSM-IV, and anIPTmanual adapted to the Haitian context.Supervision checklists for each role providerdelineated each step in depression diagnosis,management and service delivery, furtherstandardising supervisors’ approach. Psy-chologists who excelled at IPT, which wasnowbeing taught regularly during site visits,began to supervise other psychologists (andsocial workers).Weekly supervision sessions,lead by an American expert in IPT, shiftedfrom case discussion to learning how tosupervise e¡ectively. Thus, the training thetrainer approach became a focus of the sys-tems building process.Additional supervision opportunitiesincluded case presentation through tele-phone and weekly case discussions. Psychol-ogists respectively presented cases using alearning tool the team developed, andshared complex cases while the psychiatristdocumented ¢ndings on a chalkboard. Aconsistent (at least weekly), standardisedapproach to supervisionwas critical to famil-iarising and engaging psychologists in thesupervision process. Psychologists even-tually became amenable to presenting cases,soliciting insight from their supervisors andpeers, and implementing a bio psychosocial,multidisciplinary approach.Because a weekly site visit was needed tobuild capacity, team supervisors could onlyvisit three of the 11 sites each week for super-vision. However, they continued ¢eldingrequests, usually by phone, from all 11 sitesfor support managing complex psychosis,epilepsy and depression cases. Even at the


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three sites visited, clinical needs competedwith supervision and quality of care, as psy-chologists sometimes scheduled ten patientsfor the clinical supervisor. A detailed, struc-tured site visit protocolwas, therefore, devel-oped to manage this tension between thetime required for clinical care versus super-vision. Psychologists were asked to scheduleonly 3^4 patients for each supervisor visit,90 minutes per patient to allocate su⁄cientsupervision time, to block time for a shortmeeting to review clinical cases and supervi-sion goals before seeing patients, and a clos-ing meeting to review the day’s activitiesand assign homework.Team supervisors alsobegan using a site visit checklist, developedby the team psychiatrist, to evaluate clinicalcare, service delivery, systems building,MEQ, management and leadership per-formance of all role providers.This feedbackshaped subsequent site visits by drawingattention to strengths and weaknesses. After4^5 weekly visits, psychologists acclimatedto the protocol, and after 3^4 months ofweekly visits their skills, clinical and other-wise, improvednoticeably.Monthly psychol-ogist meetings, designed to avoid neglectingother sites, addressed common gaps inknowledge and again emphasised key super-vision tools (mhGAP, DSM-IV, the IPTmanual and the depression trainingmaterials). Furthermore a comprehensivetest, based on these tools, was announcedand psychologists received sample questionsin the preceding months to prepare andreview key concepts.

Direct supervision as key to servicedelivery and systems buildingchallengesOrganisational skills related to schedulingand proper storage of patient ¢lesrepresented a crucial ¢rst step in improvingservice delivery and systemsbuilding.There-fore, team supervisors began supervisiononly after organisation was satisfactory,sometimes spending several hours arranging


patient ¢lesbefore starting.Team supervisorsprovided ¢ling cabinets, folders, calendarsand post-it notes.They also required patientappointments to be entered into a calendarand providing patients with appointmentreminders on small note cards. Folders facili-tated more complete patient dossiers, whichwere stored securely in their o⁄ces, bypass-ing the central archives in order to avoid los-ing ¢les. This impromptu archive systemenhanced supervision as well by allowingsupervisors to review dossiers in order toensure that mental health evaluations werecomplete, ZLDSIs were performed at eachvisit, and follow-up forms were used for eachfollow-up visit. All of these interventionsresulted in more predictable andmanageable schedules.Further, team supervisors reviewed incom-plete ¢les with psychologists andmade plansto complete evaluations, often by seeingthese patients together. Once compliancewas achieved, psychologists appreciatedhow quality and e⁄ciency of care improved,therebyallowingmore time forother compe-tencies, suchas the registry.Team supervisorsalso required psychologists to enter patientdata into the registry immediately after see-ing each patient, rather than once permonth. Consistent accountability for the ful-¢lment each of these interventions, and foreach case, represented the key to successfulimplementation.Improving patient engagement and reten-tion required supervisors to review registriesindependently to identify all cases of con-cern, for example, epileptic patients whohad not been seen in six months or a psycho-tic patient who came once, but neverreturned. They subsequently worked withpsychologists to devise a re-engagementplan, based on acuity, for example, throughcollaboration with CHWs, calling patientsdirectly, or less often making home visits.Psychologists often felt uncomfortable withthis comprehensive review of their work,which they experienced as critical oreven judgmental. Most team supervisors,


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unaccustomed to reviewing caseloads sys-tematically and transparently, felt intrusive.Therefore, the team psychiatrist accom-panied team supervisors and psychologistsfor these reviews, demonstrating theirimportance for quality of care. As thebene¢ts for patient care became clearer, thepractice became more routine and lessuncomfortable.The site visit checklist facili-tated the development and implementationof this intervention, which taught psycholo-gists how to review their registries period-ically to identify lost cases.The psychologist supervisor observed psy-chologists presenting cases to physicians,and provided feedback to improve presen-tation and formulation, while drawing onthe supervision checklist devised to standar-dise these collaborations. Enhancing collab-oration with CHWs required morescrutiny, monitoring and follow-up to guar-antee action. Team supervisors reviewedpatient registries independently, identi¢edcases that warranted collaboration, andscheduled patient visits, with both CHWsand psychologists present. Team supervisorswould then subsequently contact both theCHW and psychologist to ensure the visittranspired. Less involved approaches, suchas recommendingCHWinvolvementduringclinical supervision of a case or during teammeetings, were unproductive. Similar toclinical supervision, service delivery and sys-tems building supervision required at least3^4 months of weekly supervision to sustaincapacity building.While collaboration withphysicians improved, collaboration withCHWs lagged behind (Table 4). Althoughseveral social workers began to work moreclosely with psychologists, most remainedlargely uninvolved in mental health care.

Solutions to monitoring andevaluation challengesAs with all other competencies, increasingthe use of the registry required direct super-vision and accountability to ensure properimplementation. The ZL MEQ supervisor


worked alongside psychologists to reviewindividual patient dossiers and to ensurepatient data were properly entered into theregistry. Registries were also carefullyreviewed to ensure that monthly reportswere accurate. During site visits, team super-visors checked registries for accuracy andto drive clinical supervision by highlightingtreatment retention or disengagement, fre-quency of visits, accuracy of diagnosis andproper treatment plans. They reviewedmonthly reports during morning meetingsin order to shape systems building e¡ortsfor the day, such as increasing collaborationwith CHWs. Despite these interventions,discordance between registries and monthlyreports, in terms of number of patients, visitsand treatments, remained as high as 60%.As a result, the team psychiatrist workedwith team supervisors and the ZL MEQsupervisor to reduce the number ofindicators, clarify their de¢nitions, andreconsider the validation process. The teamis also planning to include several newindicators to track patient satisfaction andclinical improvement with the hope of focus-ing more on quality of care. Most psycholo-gists accepted direct clinical and MEQsupervision as their skills improved, andtheir con¢dence grew as a result, but man-agement interventions were required toincrease its uptake.

Leadership/managementinterventionsShifting psychologists’ role from providingindividualisedcounsellingwith limited scru-tiny to leading clinical, service delivery, sys-tems building and activities with increasedoversight, required signi¢cant managementinterventions. A Psychologist Competencies

document, developed several months posttraining, presented new expectations, thesystem for ensuring compliance and con-sequences for non compliance. It formalisedthe process of identifying non compliant psy-chologists and developing remediationplans, as well as help identify exceptional


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Table 5. Recommendations for optimising tasksharing when initiatingcommunity basedmental health services in low resource settings

�Includeapre-implementationphaseto engageall stakeholders, tomakeacase for integratingmental health, and to assess the training needs of non specialist providers.

�Develop a detailed implementation plan that accounts for existing resources, particularlyhuman resources, and capitalises on community strengths.

� Pilot the project at several selected sites to identify strengths, weaknesses and strategies forsuccess; then apply these lessons to additional sites.

�Assign appropriate roles and skill packages to patients, families, community leaders,traditional healers and community healthworkers. Do not under estimate the capacity ofnon specialist providers.

�Designtrainingsthatnotonlyteachclinical skills, butalsoemphasisewhateachroleprovideris supposed to do to advance a community based system of care.

� Follow intensive trainings immediately with consistent, direct supervision, standardisedusing tools and protocols, and led by a clinical expert.

� In settingswhere trainings canonly last severaldaysand supervisors are few, develop simple,practical tools (like checklists) to facilitate ongoing learning.

�Create training manuals that are adapted to local culture and realities, and train roleproviders to use tools and protocols.



psychologists, who were subsequently con-sidered for promotions and leadership pos-itions. Collaborating with physician andnursing leadership within ZL has beenespecially important for improving theseproviders’ involvement in the ZL mentalhealth care model.

DiscussionOurmodel, inwhichpsychologists emerge asthe leaders in mental health systems build-ing, demonstrates how taskshifting as atheory translates into daily practice ando¡ers practical, implementable solutions tofacilitate this process (see Table 3). It alsoillustrates how bringing together a clinicalexpert (an American trained psychiatrist)and mental health care providers withexpertise within the local context (the ZLmental health team) can enhance scale-upe¡orts. The process of taskshifting diverseresponsibilities took place within the largercontext of a three-year e¡ort to scale up com-munity based mental health servicesThere-fore, in addition to providing practical


solutions inTable 3, we also present a criticalappraisal of the project and its ambitiousplans to taskshift leadership responsibilitiesto psychologists. Broader points, that couldbe applied to similar early stage e¡ortslaunched in other resource-challenged set-tings, are presented inTable 5.Prior to the depression care pathway, mentalhealth had a limited presence within ZL,which had instead focused on medical care,particularly related toHIV/AIDS. Psycholo-gists primarily supported these e¡orts andoccupied a marginal role at best. Therefore,when implementation began, the case forintegrating mental health services was notestablished. In particular, nursing, physicianand social worker leadership were not fullyand practically committed to the mentalhealth scale-up plans. For these reasons, theproject needed a pre implementation phase:1) to advocate for mental health amongclinical leadership; 2) to sensitise ZL to theimportance of mental health integration;and 3) to create a detailed, practical imple-mentation plan that accounted for the team


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supervisors’ limited supervision capabilities(Thornicroft et al., 2010; WHO, 2013;WHO/World Organisation of FamilyDoctors, 2008). Piloting the project at threeZL sites also could have identi¢ed strengths,weaknesses, and e¡ective strategies fordeveloping services at the other eight(WHO, 2013). Instead, implementationitself, which took place simultaneously at 11sites, revealed the major challenges: 1) lackof collaboration between role providers;and 2) psychologists’ limited knowledge ofbasic mental health care. Both of theseobstacles, in turn, made psychologists’additional service delivery and monitoringand evaluation responsibilities too onerous.Also, with the depression care pathwaycentred heavily on psychologists within aclinic setting, may have underestimatedcommunity assets. The skill packagesmapped across providers (Figure 2), forexample, did not include families and com-munity members (Thornicroft et al., 2010).Furthermore, ZL CHWs have contributedrobustly to the depression care pathway,going beyond case identi¢cation and clinicreferral. Using interpersonal therapy, theyhave successfully treated more severelydepressed patients who had been unable toaccess clinic based care. Their educationaland awareness raising activities havereduced stigma and engaged communityleaders and traditional healers, some ofwhom, in turn, refer mental health cases.They have also facilitated family involve-ment through psychoeducation and support,and some of their treated patients have evensupported other community members toseek mental health services.The ZL depression trainings were limited intheir capacity as starting points for articulat-ing the care pathwayandequipping psychol-ogists to develop comprehensive,multidisciplinary care. Logistical challengesrelated to funding, transport, housing andfood, limited the trainings to several days,rather than the several weeks or more thatare often needed to train non specialist


mental health providers (WHO,2013).Thesechallenges also prevented nurses, physicians,social workers, psychologists, and CHWsfrom training together to facilitate team-building at each site. Content focusedprimarily on diagnosis, evaluation, andtreatment anddid not emphasise the systemsbuilding process by highlighting what eachrole provider is expected to do. Furthermore,too few role providers were trained in orderto instigate systems wide changes (forexample, 11 out of the 90 total physicians atZL; 21 out of the 220 total nurses at ZL).Because ZL psychologists were givenmultiple new demands simultaneously, theyneeded consistent, direct supervision to sus-tain learning following the trainings(WHO, 2013). However, only one psycholo-gist supervisor was available to train 12 psy-chologists at 11 sites, making weeklysupervision impossible.The shortage of teamsupervisors alsomade e¡ectively supervisingall other service providers problematic,further interfering with psychologists’leadership role.However, despite these challenges, lessonsfrom the depression care pathway informedthe epilepsy system of care’s developmentand implementation in the following year.Curricula materials were developed withgreater attention to the local context andconsideration of community resources. Forexample, psychologists were trained to elicitand understand patients and families’expla-natory models, which are also factored intopsycho education messages. CHWs receivedmore guidance about community educationactivities and counselling patients andfamilies. Novel training manuals developedfor each role provider, which served as thebasis for the epilepsy trainings, focus onhow to use practical, simple tools, such asepilepsy evaluation forms and an epilepsychecklist.They also emphasise the roles eachprovider plays in bringing the system of caretogether. These tools have successfullyguided role providers who were unable toparticipate in the trainings and helped


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ensure higher quality care. All of thesechanges have facilitated psychologists’ lea-dership role in the epilepsy care pathway,while direct supervision, immediately fol-lowed the trainings, have ensured betterimplementation.Nonetheless, psychologists continue toman-age demanding caseloads of complex caseswithoutadequate supervision,duetohumanresources constraints. As a result, both sec-ondary trauma and burnout remain realrisks. The ZL team has considered shiftingmore depression cases to CHWs in the com-munity, but only several dozen of the severalhundred ZL CHWs has been trained in thedepression care pathway.The availability ofstrong clinical supervisors to oversee andensuresafe,qualitycareremainstheratelim-iting step. Currently, there are only threefully e¡ective supervisors (the psychologistsupervisor, the CHW supervisor, and theteam psychiatrist) for a team that hasscreened over 5,000 individuals for depres-sionsincetheprojectbegan.Infuturepapers,the ZL team will highlight the experienceof other roles providers, particularly CHWsand physicians, in the depression and epi-lepsy care pathways, thereby providing amore comprehensive, critical appraisal oftheir community based, mental healthscale-up e¡orts.

ReferencesBelkin, S., Unˇtzer, J., Kessler, R., Verdeli, H.,Raviola, G., Sachs, K., Oswald, C. & Eustache,E. (2011). Scaling up for the ‘‘bottombillion’’: ‘‘5�5’’ implementation of community mental healthcare in low-income regions. Psychiatric Services, 62,1494-1502.

Bolton, P., Surkan, P., Gray, A. & Demousseaux,M. (2012). The mental health and psychosociale¡ects of organized violence: a qualitative studyin northern Haiti.Transcultural Psychiatry, 49, 590-612.

Brodwin, P. (1996). Medicine and morality in Haiti:

The contest for healing power. NewYork: CambridgeUniversity Press.


Cerda¤ , M., Paczkowski, M., Galea, S., Nemethy,K., Pe¤ an, C. & Desvarieux, M. (2012). Psycho-pathology in the aftermath of the Haitiearthquake: A population-based study of post-traumatic stress disorder and major depression.Depression and Anxiety, 30, 413-424.

Farmer, P. (1994).The usesofHaiti.Monroe,Maine:Common Courage Press.

Rasmussen, A., Eustache, E., Raviola, G., Kaiser,B., Grelotti, D. & Belkin, G. (2015). Developmentand validation of a Haitian Creole screeninginstrument for depression.Transcultural Psychiatry,52, 33-57.

Raviola,G.,Eustache,E.,Oswald,C.&Belkin,G.(2012).Mentalhealthresponse inHaiti intheafter-math of the 2010 earthquake: A case study forbuildinglong-termsolutions.HarvardReviewofPsy-chiatry, 20, 68-77.

Raviola, G., Severe, J.,Therosme,T., Oswald, C.,Belkin, G. & Eustache, E. (2013). The 2010 Haitiearthquake response.ThePsychiatric ClinicsofNorth

America, 36, 431-450.

Smith-Fawzi, M. K., Eustache, E., Oswald, C.,Surkan, P., Louis, E., Scanlan, F., Wong, R., Li,M. & Mukherjee, J. (2010). Psychosocial func-tioning among HIV-a¡ected youth and theircaregivers in Haiti: implications for family-focused service provision in high HIV burdensettings. AIDSPatient Care and STDs, 24,147-158.

Sontag S. (2010) In Haiti, mental health system isin collapse. NY Times.

Thornicroft, G., Atalay, A., Dos Santos, R., Bar-ley, E., Drake, R., Gregorio, G., Hanlon, C., Ito,H., Latimer, E., Law, A., Mari, J., McGeorge,P., Padmavati, R., Razzouk, D., Semrau, M.,Setoya,Y.,Thara, R. & Wondimagegn, D. (2010).WPA guidance on steps, obstacles, and mistakesto avoid in the implementation of communitymental health care.World Psychiatry, 9, 67-77.

Wagenaar, B., Hagaman, A., Kaiser, B., McLean,K. & Kohrt, B. (2012). Depression, suicidalideation, and associated factors: a cross-sectionalstudy in rural Haiti. BMCPsychiatry, 12,149.


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Wagenaar, B., Kohrt, B., Hagaman, A.,McLean,K. &Kaiser, B. (2013). Determinants of care seek-ing formental health problems in ruralHaiti: cul-ture, cost, or competency. Psychiatric Services, 64,366-372.

World Health Organization (2008).Task shifting:Global recommendations and guidelines.

World Health Organization (2011). La Systeme deSanteMentale.


RupinderLegha is thePagenelFellow inGlobalMen

in Health and HarvardMedical School’s Program in

email: [email protected]

Eddy Eustache is the Director ofMental Health and

Haiti.

TatianaTherosme is theMentalHealth andPsychoso

Community HealthWorkers at Zanmi Lasante, Hait

Kate Boyd is currently a Doctorate in Public Health

USA.ShewaspreviouslytheMentalHealthandPsyc

Haiti.

Fils-AimeReginald iscurrentlya student in theMast

HarvardMedicalSchool,USA.Hewaspreviouslythe

Mental Health Supervisor for Physicians at Zanmi L

Gertruna Hilaire is the Coordinator forMonitoring

ShinDaimyo is currently SeniorAdvisor forMentalH

Nursing candidate at theYale School of Nursing, and

the Clinical Programs O⁄cer and ProgramManager

GregoryJerome is the Director of Monitoring and

Lasante, Haiti.

HelenVerdeli is an Associate Professor of Psychology

Health Lab atTeacher’s College, Columbia Universit

GiuseppeRaviola is theDirectorofMentalHealth at

Program in Global Mental Health and Social Cha

Department of Global Health and SocialMedicine,

World Health Organization (2013). Building backbetter: Sustainablemental health care after emer-gencies.

World Health Organization/Pan AmericanHealth Organization (2010). Culture and mentalhealth in Haiti.

World Health Organization/World Organizationof Family Doctors (2008). Integrating mentalhealthcareintoprimarycare:Aglobalperspective.


talHealthDelivery,which issponsoredbyPartners

GlobalMental Health and Social Change, USA.

Psychosocial Support Services at Zanmi Lasante,

cial SupportTeam’sMentalHealth Supervisor for

i.

candidate at the Colorado School of Public Health,

hosocialSupportCoordinatoratPartners inHealth,

ers inMedicalScience inGlobalHealthDeliveryat

MentalHealthandPsychosocialSupportServices’

asante, Haiti.

and Evaluation at Zanmi Lasante, Haiti.

ealth at Partners inHealth, aMasterof Science in

a Paul andDaisy Soros Fellow.He was previously

forMental Health at Partners in Health, USA.

Evaluation and Quality Improvement at Zanmi

and Education and Director of the GlobalMental

y, USA.

Partners inHealth,Boston; and theDirectorof the

nge, which is based at Harvard Medical School’s

USA.

267

mailto:[email protected]

taskshifting: translating theory into practice to build a

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